Q & A: The Facts About Cholesterol

Learn About Lipids from Dr. Mark Benson, Director of Cardiovascular Disease Prevention

The Outpatient Lipid and Cardiovascular Disease Prevention Clinic in the CardioVascular Institute at Beth Israel Deaconess Medical Center helps patients identify and manage risk factors that could lead to heart disease. The clinic has particular expertise in developing treatment strategies for patients with high cholesterol, or patients who have had difficulty taking cholesterol-lowering statin medications in the past.

Director of Cardiovascular Disease Prevention Mark Benson, MD, explains why the decision of whether or not to begin statin medication is based on a personalized treatment plan that takes into account an individual’s risk factors as well as medical and personal concerns.

How much can lowering cholesterol protect against heart disease?

Mark Benson, MD: Many large clinical studies have clearly demonstrated that you can reduce the risk of having a heart attack or stroke by lowering levels of “bad” LDL (low density lipoprotein) cholesterol. From research done with statin medications, we know that for every 40 points that you lower LDL, you can expect to decrease your annual risk of having a heart attack, stroke or heart disease by about 20 percent.

Numbers will vary depending on an individual’s medical history, but we generally recommend that LDL levels be 100 mg/dl or lower.

When is medication needed?

Dr. Benson: Before considering statins or other cholesterol-lowering medication, we first look at lifestyle modifications. Weight loss, daily aerobic exercise, and reduced dietary cholesterol are the cornerstone of all cholesterol-lowering strategies and can often have a significant impact, reducing cholesterol by 5 to 10 percent. These lifestyle modifications can also have important additional benefits for cardiovascular health.

The decision about whether or not to begin treatment with statins or other medications is based on a careful evaluation and discussion between our clinical team and the patient. In general, we suggest the addition of medication when it would lead to a substantial reduction in your personal risk of heart disease. Doctors define cardiovascular risk as the chance of a heart attack or stroke occurring within the next 10 years. This calculation is based on a number of risk factors, including:

• High cholesterol
• High blood pressure
• Smoking
• Diabetes
• Age
• Gender
• Race
• Family history

Individuals who have known cardiovascular disease (a prior heart attack, stroke, peripheral artery disease), diabetes, genetically high cholesterol levels, or a strong family history of cardiovascular disease are at high risk for heart disease and may benefit from adding a medication to their treatment plan.

On the other hand, if your baseline risk for developing cardiovascular disease is low, the added benefit that you could expect from starting a cholesterol-lowering medication would likely not justify the cost, inconvenience and risk of possible side effects associated with starting a new medication.

More about high cholesterol

What are the benefits and side effects of statins?

Dr. Benson: Statins are the most commonly used cholesterol-lowering medications and have a long, well-studied track record. They are effective at lowering LDL cholesterol by about 30 to 60 percent and reduce the risk of heart attack and stroke.

But as with any medication, this benefit does come with possible side effects. Fortunately, serious side effects are extremely rare, and we can often recognize who might be at increased risk for problems.

Muscle-related symptoms from statins, including soreness and muscle weakness, are relatively common and are likely to affect as many as 20 percent of individuals who start these medications. These symptoms are usually mild and go away after the first week or two.

However, for some people, these symptoms disrupt their quality of life and require that use of the medication be discontinued. It’s estimated that as many as a third of patients who are prescribed a statin stop taking it within the first year due to side effects or concern about side effects.

Fortunately, we now have substantial experience with these symptoms and can almost always find an alternative medication. There are now many different statin and non-statin options (including the new PCSK9 inhibitors) available. The key is that each individual — with their specific genetic makeup, personal and family history, and environmental exposures — is unique and the medication strategy that will ultimately work for them is equally personalized.

What takeaway advice would you give patients?

Dr. Benson: The beautiful thing about the role of cholesterol in preventing cardiovascular disease is that it can be modified. The first step is to get a cholesterol test so you know your numbers. The next step is to talk with your physician to design a strategy that will help you reach your personal cholesterol goals.

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